| Please provide the name and address of the employer involved: |
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| Approx. # of employees at company: |
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| Are you a current__________of this employer? |
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employee
former employee
job applicant
prospective employee
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| Are you presently employed? |
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yes
no
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| If so, please provide your job title and employer's name and address: |
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| Can you be contacted at work? |
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yes
no
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| Describe your situation, including any relevant dates: |
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| Are you a union member? |
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yes
no
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| If yes, provide the name, address and local number: |
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| Have you made a complaint about your situation to any governmental agency? |
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yes
no
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| If yes, provide the name of the agency, the date you made your complaint, and the final result, if any, of your complaint: |
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| Are any other people involved? |
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yes
no
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| If yes, provide the names, addresses (if known), and their relationship to you, if any: |
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| Do you have any documents that could help explain your situation? |
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yes
no
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| If yes, list those documents and their dates: |
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| Are there other documents that you do not have access to that could be of assistance? |
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yes
no
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| If yes, list those documents and their dates and locations (if known): |
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| Describe how this situation has impacted you: |
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| Describe what you would like to happen to resolve your issue (your preferred outcome): |
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| Have other attorneys worked on this matter? |
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yes
no
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| If yes, provide names, addresses, and a brief description of their involvement: |
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| Special concerns: |
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| Where did you hear about this site? |
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